WHEREAS, EMPLOYEE is an Employee of an Employer, or Business Entity which has contracted with Regional Care, Inc. (RCI) and or with SBA COOP to provide a Partially Self-Funded (ERISA) Employer/Employee Health Benefit Plan. Employee hereby elects to enroll in the Employer Member’s Sponsored ERISA Health Plan known as: “EMPLOYER FREEDOM PLAN” administered by Regional Care, Inc. (RCI). Employee understands and agrees to and authorizes RCI and or SBA COOP, on behalf of Employee, a provision for all billings and payments there under to be made through RCI or its designee for the account of the Employee(s) involved, including but not limited to assignment of benefits where agreed to and appropriate.
Service Agreements: Employee may enter into one or more Service Agreements (Enrollment Forms- Insurance Applications) through RCI and or SBA COOP, each of which Agreements shall be deemed incorporated herein by reference when separately executed and delivered.
IN WITNESS WHEREOF, by your signature appearing below, you have agreed to the Enrollment Application in the Employer Sponsored Freedom Plan as of the date and year appearing next to your signature.
I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and until RCI approves both this enrollment form and the employer application. I agree that my employer or its agent may send this enrollment form to RCI. I authorize all my doctors, pharmacies, hospitals and other health care providers (“Providers”) to give RCI any and all personal health information about me and others listed on this form. This authorization covers all health matters including those involving mental health, substance abuse and HIV/AIDS. I further authorize RCI to use such information and to disclose such information to affiliates, Providers, payors, other insurers, third party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original.
I certify that all information and statements on this enrollment form are true and complete to the best of my knowledge and that I have authority to make statements on behalf of any dependents listed on this form. I am employed by the employer on page 1 and working full-time for this employer.
By signing this form, Employee acknowledges his/her understanding that the Annual Base Plan Maximum does not exceed the plan amount selected. Annual Base Plan Maximum is either $7,500, $10,000, or $25,000. Depending upon Eligible claims above these amounts are the responsibility of the Employee.